Inspite of so much development in medical technology, Tuberculosis (TB) is still the problem for humans. Few studies, in Pakistan highlighted the factors that affect patients health related quality of life (HRQOL) with active TB. The aim of this study is to measure short form six dimension (Sf-6D) utility scores of patients with active TB of Sargodha district. 120 active TB patients were interviewed and short form-36 questionnaire was followed. District TB hospital of Sargodha district was visited. Results show that Utility scores of female patients were better than male, while patients belong to urban areas have better utility scores as compared to rural patients of TB. Indoor patient’s utility scores were better than outdoor patients. Disease severity, use of drugs, depression, pain and death threat were the factors that negatively affect the patients health related quality of life, while opportunity of leisure and income level increase patients HRQOL.Sf-6D, Pakistan, TB

Aslam, Muhammad Amir

Awan, Masood Sarwar

Sarwar, Muhammad

Waqas, Muhammad

English

Research Papers in Economics

Measurement of SF-6D Utility among Patients with Active Tuberculosis
Masood Sarwar Awan
Assistant Professor, Department of Economics University of Sargodha, Pakistan
Tel: 92-300-870-4388   E-mail: awan811@hotmail.com
Muhammad Waqas
Graduate Student, Department of Economics University of Sargodha, Pakistan
Tel: 92-321-860-0229   E-mail: economist147@hotmail.com
Muhammad Amir Aslam
Research Scholar Department of Social Work, University of Sargodha, Pakistan
Tel: 92-321-600-7062   E-mail: amir_aslam22@yahoo.com
Muhammad Sarwar
Assistant Professor Department of Education, University of Sargodha, Pakistan
Tel: 92-321-860-0055   E-mail: drsarwar@ymail.com
Received: October 20, 2010   Accepted: November 5, 2010
Abstract
Inspite of so much development in medical technology, Tuberculosis (TB) is still the problem for humans. Few 
studies, in Pakistan highlighted the factors that affect patients health related quality of life (HRQOL) with active TB. 
The aim of this study is to measure short form six dimension (Sf-6D) utility scores of patients with active TB of 
Sargodha district. 120 active TB patients were interviewed and short form-36 questionnaire was followed. District 
TB hospital of Sargodha district was visited. Results show that Utility scores of female patients were better than 
male, while patients belong to urban areas have better utility scores as compared to rural patients of TB. Indoor 
patient’s utility scores were better than outdoor patients. Disease severity, use of drugs, depression, pain and death 
threat were the factors that negatively affect the patients health related quality of life, while opportunity of leisure 
and income level increase patients HRQOL.  
Keywords: Sf-6D, Pakistan, TB
1. Background 
In clinical research measure of health related quality of life is very important. Every disease has some explicit and 
implicit effects on the life of the patient. Use of medicines may cure the patient from infection but seems to be 
ineffective to reduce the physical, psychological and mental distortions which he or she faces during infection time 
period. 
Assessment of HRQOL has become important area of conversation and researchers paid their attention towards 
public health issues during past years. Disease affects the patient's daily activities, economic condition, social life 
etc. HRQOL instrument consist on those domains which affect the patient's explicit life functioning. Person's 
perceptions about his physical, psychological, social, mental, economic and spiritual functioning are referred as 
HRQOL.
With the development of effective medical treatment tuberculosis is still considered as a dangerous disease. TB is 
the second common disease after HIV, which creates deaths. According to estimates of 2007 two billion people are 
1under the risk of TB, whereas it causes the death of 1.7 million people all over the world. TB destroys respiratory 
system, tissues and other organs of the body. This disease spreads through coughing, sneezing, talking etc.
The people in age group of 15-59 years are mostly hit by this disease, which shows that it creates major economic 
burden for individuals and hence for countries. Most of the Asian counties like Pakistan, India, China, Bangladesh 
and Indonesia accounted more than half of the world disease burden. Among 22 highest disease burden countries, 
Pakistan is at 22
nd number where 286000 new cases appear per year. Punjab is the most populous province in 
Pakistan, where 0.3 people of the population are diagnosed with active TB and 2.2% people are under the symptoms 
of TB. Sargodha is the eight largest district of Punjab, where 0.4 of people are diagnosed with active TB and 4.4% 
are under severe symptoms of TB. Different studies explore the HRQOL of TB patients; however a little works is 
done by researchers on this aspect with reference to Pakistan.  The intension of this study is to explore the HRQOL 
of TB patients in Sargodha. The study use SF-36 questionnaire to construct SF-6D utility algorithms. Moreover this 
study highlights the factors that affect the HRQOL of TB patients of Sargodha.
The rest balance of paper is designed as: part two explains about the SF-6D Utility Algorithm, part three discuss the 
literature review, part four discuss the data sources and empirical methodology, part five investigates and interprets 
the empirical results. Finally, part six presents the conclusions of the study and also provides some policy 
implications.
2. SF-6D Utility Algorithm
SF-6D converts the eight domains of SF-36 into six domains. It is a generic preference based single index, which 
generates health utility algorithms. It describes 18,000 health states and the utility values, which shows that 
the value of full health as 1 and 0 for poor health. SF-36 and SF-12 questionnaires are only used to generate 
the utility values form SF-6D.   
3. Review of Literature
Khan et al. (2000) showed that most of the Pakistani patients were poor even than they preferred private 
practitioners. Study also showed that patients are reluctant to disclose their disease but the same time they are facing 
some social as well as economic problem.  
Guo (2009) found that TB effect HRQOL of patients negatively. 310 patients of Canada were interviewed by using 
SF-36 and health utility index 3 (HUI-3). Study also reviewed the different studies which were done on HRQOL 
during 1981-2008.  Results showed that after treatment, HRQOL was better in TB patients. Moreover, mental health 
recovery was low as compared to physical health recovery in TB patients. 
Marra et al. (2008) tried to examine HRQOL of active and latent TB patients of Vancouver by using SF-36. Beck 
depression inventory was used to check the severity of depression among TB patients. 104 and 102 patients of active 
and latent TB were interviewed respectively. Scores of SF-36 of active TB patients were low as compared to latent 
TB patients, whereas Beck DI scores were in better condition in latent TB patients than active patients. Ordinal 
logistic regression results showed that age, HIV and hypertension were significantly related to quality of life scores, 
whereas diabetes and drinking showed insignificant relationship. 
Muniyandi (2007) used SF-36 to investigate HRQOL in the patients with TB whose treatment was completed and 
they were cured. The study interviewed 436 patients of India. Mean score of economic well being was 62 whereas; 
mental, social and physical scores were 68, 84 and 74 respectively. Study concluded that education, employment, 
age, persistent system and sex was associated to well being. 
Pasipanodya (2007) tried to explore HRQOL of those patients who completed a treatment of 20 weeks. Study used 
St. George Respiratory questionnaire (SGRQ) and interviewed 105 pulmonary TB patients. 
Dhingra (2005) tried to explore the HRQOL by making serial HRQOL assessment between the patients during anti-
tubercular therapy and after completion of treatment. DR-12 questionnaire was used and 76 patients of pulmonary or 
extra pulmonary patients on DOTS were interviewed. Results showed that those patients have higher scores of 
HRQOL who have higher outcomes after treatment than the patients having lower outcomes.
24. Data Sources and Methodology
120 patients of TB are interviewed from Sargodha district. For this intention Divisional TB Hospital of Sargodha is 
visited. SF-36 questionnaire is used along with data on age, disease severity, gender, education, vaccination, 
income, region and drug addiction. Age of disease is used as a proxy for disease severity.  The SF-6D offers 
a way for using the SF-36 and estimate preference-based single index for economic evaluation. By utilizing 
ordinary least square (OLS) method Multiple linear regression analysis is performed to explore the factors 
that affect HRQOL of TB patients. 
0 1 2 3 ......(1) HRQOL gender age region a a a a e = + + + +
0 1 2 3 ....(2) HRQOL dissevr patype drugus a a a a w = + + + +
0 1 2 3 4 5
6
ln
...(3)
HRQOL pain depr sleep income dthr
leisur u
a a a a a a
a
= + + + + + +
+ KKKK
First model is the demographic model, which shows the impact of demographic variables on HRQOL with active 
T.B. second model shows the impact of medical variables, where independent variables are disease severity 
(dissevr), type of patient (patype) and use of drugs (drugus). Third model shows the impact of physical and 
psychological thinking of patient’s HRQOL, where pain (pain), depression (depr), sleep (sleep), log of 
income (lnincome), death threat (dthr) and opportunity of leisure (leisur) are independent variables.
5. Results and Discussion
The data shows that 59.2 percents of active T.B are males, while the females are 40.8 percent. The percentage of 
rural patients is 57.5, whereas 42.5 percent belongs to urban areas. This shows that active T.B is higher in 
rural areas than urban. This study also distinguished the patient into two categories, indoor and outdoor. 
Indoor patients are those patients, who admit in the hospital for treatment, while outdoor patients are those 
who do not admit in the hospital for the treatment of disease. They just go to hospital get their medicines. 
Indoor patients are 37.5 percent, while 62.5 percent are outdoor patients. Four types of active T.B are 
identified in our study; pulmonary, bones, lungs and throat.  57.5 percent patients caught by pulmonary T.B, 
whereas 18.3, 23.3 and 0.8 percent are the patients of bones, lungs and throat T.B, respectively. 80.8 percent 
patients lived in airy homes, while 19.2 percent lived in closed houses. Percentage of married patients is 78.3, 
while 20 percent are unmarried and 0.8 percent of patient with active T.B are divorced and separated.      
Most of the patients are uneducated (65.8 percent), while 12.5 percent patients completed Primary level education. 
10.8 percent completed Middle level education, while 6.7, 2.5, 0.8 and 0.8 percent patients completed their 
Metric, Inter, Bachelor, and Masters level education, respectively. 44.2 percent are smokers and 1.7 percent 
are drinkers whereas, 55.8 percent are the patient who used no drugs. Out of 120 patients, 22.5 percent 
patients have an under ground sewerage system, while 71.7 percent have open sewerage system. 5.8 percent 
patients have no sewerage system. 74.2 percent patients feel bodily pain due to TB, while 76.7 percent 
patients feel depression. 74.2 percent patients of active TB   caught by threat of death, whereas leisure 
improves the quality of life, but our results shows that 60 percent of patients have no opportunity of leisure 
(see table 1 & 2).
5.1 Multiple regression results
3In our analysis dependent variable is SF-6D utility scores. In first model independent variables are gender (male=1, 
0 otherwise), age of the patient and region (urban=1, 0 otherwise). All the variables are significant except 
gender. Age of the patient was significantly negatively related to utility scores. Negative sign of the 
coefficient of region explores the fact that rural patient quality of life is better than urban patient. Moreover, 
if the patient is female her quality of life is better than male patient.  
Second model results show that disease severity negatively affect the patient quality of life. Negative sign of the 
coefficient (type of patient) shows that indoor patient quality of life is superior as compared to outdoor 
patients. Moreover, results show that the patients who use drugs their quality of life is worse than the patient 
who is not using any type of drug.
Results of third model show that the negative sign of the coefficients of depression depicts that depressed patient’s 
quality of life is worse than the patient who has no depression. Same as, the patient who has no pain and 
death threat his quality of life is better than the patient caught by pain and death threat. The patient who has 
an opportunity of leisure enjoys better quality of life than the patient who has no opportunity of leisure. 
Income shows positive relationship with quality of life, which shows that as income increase the patient’s 
quality of life also increases (see table 3).
6. Conclusions
The rationale of this study is to measure Sf-6D utility scores of patients with active T.B. this is also the aim of the 
study to finds the factors that affect the HRQOL of patients with active T.B of Sargodha district. 120 active 
T.B patients are interviewed by visiting District T.B hospital of Sargodha district. Results shows that Utility 
scores of female patients are better than male patients, while patients belong to urban areas have better utility 
scores as compared to rural patients of T.B. Multiple regression analysis results show that indoor patient’s 
utility scores are better than outdoor patients. Disease severity, use of drugs, depression, pain and death threat 
are the factors that negatively affect the patients HRQOL, while opportunity of leisure and income level 
increase patients HRQOL. The study gives several suggestions on the basis of present analysis. With the 
advancement of medical technologies the treatment also should focus on those aspects that increase patients 
health related quality of life, like by giving the opportunity of leisure to patients their health related quality of 
life may be maximized. Giving them the financial assistance will also help in removing their financial 
hindrances. Government and concerning authorities should focus on controlling drugs among the people. 
Death threat and depression may be control by teaching the patients and by giving them cognitive behavioral 
therapy.        
References
Brazier, J.E., Roberts, J.R. (2004). The estimation of a preference-based index from the SF-12. Medical Care, 
42,851-859.
Dhingra, V.K., & Rajpal, S. (2003). Health related quality of life (HRQL) scoring in Tuberculosis. India J Tuberc, 
50, 99-104.
Dhuria, M., Sharma, N., Ingle, G.K. (2008). Impact of tuberculosis on the quality of life. Indian J Community Med, 
33, 58-9.
Global tuberculosis control - surveillance, planning, financing. WHO Report. (2008).
Guo, N., Marra, F., Marra, C. (2009). Measuring health-related quality of life in Tuberculosis: a systematic review. 
Health Qual Life Outcomes, 7, 1-14.
Jaggarajamma, K., Sheela, F., Narayanan, P.R. (2007). Evaluation of post-treatment health-related quality of life 
(HRQoL) among tuberculosis patients. Int J Tuberc Lung Dis, 11,887-892.
Khan, A., Walley, J., Newel,l J., Imdad, N. (2000).  Tuberculosis in Pakistan: Socio cultural constraints and 
opportunities in treatment. Soc Sci Med., 50, 247–54.
Marra, C.A., Marra, F., Cox, V.C., Palepu , A., Fitzgerald, J.M. (2004). Factors influencing quality of life in patients 
with active tuberculosis. Health Qual Life Outcomes, 20, 58.
Awan, M.S, Waqas, M., Ali, M., Aslam, M.A. (2011). Status of Health related Quality of life between HBV and 
HCV Patients of Pakistan. International Journal of Business and Social Science. 2, 213-220.
Multiple indicator cluster survey. (2007-08). Pakistan.
4Muniyandi,  M., Rajeswari, R., Balasubramanian,  R., Nirupa, C., Gopi, P.G., Pasipanodya, J.G., Miller, T.L., 
Vecino, M. (2007). Using the St George Respiratory Questionnaire to Ascertain Health Quality in Persons with 
Treated Pulmonary Tuberculosis. Chest, 132, 1591–1598. [Online] Available: http://www.worldlifeexpectancy.com; 
http://www.who.int.
5Table 1: Descriptive statistics of the data
Table 2. Short form six dimension (SF-6D) scores
Short form six dimension (SF-6D) scores
N Maximum Minimum Mean
Overall 120 0.77 0.31 0.53
Male  71 0.77 0.31 0.53
Female 49 0.75 0.33 0.54
Rural 69 0.71 0.35 0.54
Urban  51 0.77 0.31 0.52
Percentage 
Gender 
Male 
Female 
59.2
40.8
Region 
Rural
Urban 
57.5
42.5
Patient type
Indoor 
Outdoor 
37.5
62.5
Type of T.B
Pulmonary
Bones
Lungs
Throat 
57.5
18.3
23.3
0.8
Type of houses
Airy 
Closed 
80.8
19.2
Marital status
Married
Unmarried
Divorced
Separated
78.3
20.0
0.8
0.8
Education 
Never attended school
Primary level
Middle level
Metric level
Inter level
Bachelor level
Masters and above
65.8
12.5
10.8
6.7
2.5
0.8
0.8
Type of drugs
Smoking
Drinking
Use no drugs
42.5
1.7
55.8
Sewerage system
Underground 
Open system
No sewerage system
22.5
71.7
5.8
Bodily pain 74.2
Depression  76.7
Death threat  74.2
Opportunity of leisure 60.8
6Table 3. Multiple regression results
DEMOGRAPHIC MODEL
Constant 0.591***
Gender ( Male=1, Female=0) -0.007
Age of the patient -0.001**
Region  (Urban=1, Rural=0) -0.201*
R
2 0.501
F-Statistics 110.635
SER 12.366
MEDICAL MODEL
Constant 0.568***
Disease severity -0.005
Type of patient (Outdoor =1, Indoor =0) -0.014
Use of drug (Yes=1, No=0) -0.025*
R
2 0.362
F-Statistics 85.999
SER 9.110
PHYSICAL AND PSYCHOLOGICAL MODEL
Constant 0.465***
Pain (Yes=1, No=0) -0.054***
Depression (Yes=1, No=0) -0.041**
Sleep (Satisfied=1, Dissatisfied=0) 9.463**
Log of income 0.021*
Death threat (Yes=1, No=0) -0.062***
Opportunity of leisure (Yes=1, No=0) 0.020*
R
2 0.523
F-Statistics 57.336
SER 6.853
**=99% significance level    *=  95% significance level
7

Evaluation of post-treatment health-related quality of life (HRQoL) among tuberculosis patients.

Factors influencing quality of life in patients with active tuberculosis.

Global tuberculosis control - surveillance, planning, financing. WHO Report.

Health related quality of life (HRQL) scoring in Tuberculosis.

Impact of tuberculosis on the quality of life.

Measuring health-related quality of life in Tuberculosis: a systematic review.

Multiple indicator cluster survey.

The estimation of a preference-based index from the SF-12. Medical Care,

Tuberculosis in Pakistan: Socio cultural constraints and opportunities in treatment.

Using the St George Respiratory Questionnaire to Ascertain Health Quality in Persons with Treated Pulmonary Tuberculosis.

Measurement of SF-6D utility among patients with active tuberculosis

Measurement of SF-6D utility among patients with active tuberculosis

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